By Counterforce Health Team in Fintepla (fenfluramine) —

How to Get Fintepla (Fenfluramine) Covered by Blue Cross Blue Shield in Ohio: Complete Appeals Guide with Forms and Timelines

Quick Answer: Getting Fintepla Approved by Blue Cross Blue Shield in Ohio

Fintepla (fenfluramine) requires prior authorization from Blue Cross Blue Shield in Ohio. The fastest path to approval: 1) Ensure your neurologist is enrolled in the FDA REMS program and has completed your baseline echocardiogram, 2) Submit a prior authorization request documenting your Dravet syndrome or Lennox-Gastaut syndrome diagnosis with specific ICD-10 codes (G40.83 for Dravet, G40.81 for LGS), and 3) Include records of failed trials with preferred anti-seizure medications like clobazam, valproate, or cannabidiol. If denied, you have 180 days to file an internal appeal and can request external review through the Ohio Department of Insurance at 800-686-1526.

Table of Contents

Understanding Your Blue Cross Blue Shield Coverage

Blue Cross Blue Shield operates as 33 independent plans across the United States, with policies varying by state and specific plan. In Ohio, the primary Blue Cross Blue Shield presence is through Anthem Blue Cross Blue Shield, which serves approximately 31% of the state's health insurance market.

Fintepla (fenfluramine) is typically classified as a specialty medication requiring prior authorization due to its high cost—around $1,595 for a 30-mL bottle—and specialized safety monitoring requirements through the FDA's Risk Evaluation and Mitigation Strategy (REMS) program.

Coverage at a Glance

Requirement What It Means Where to Find It
Prior Authorization Required before dispensing Anthem Ohio Provider Portal
REMS Enrollment Provider must be certified FDA REMS website
Step Therapy Try preferred drugs first Plan formulary document
Diagnosis Codes G40.83 (Dravet) or G40.81 (LGS) Medical records
Appeal Deadline 180 days from denial Denial letter

Prior Authorization Requirements

Blue Cross Blue Shield requires comprehensive documentation for Fintepla approval. Your neurologist must submit:

Essential Documentation:

  • Confirmed diagnosis of Dravet syndrome (ICD-10: G40.83) or Lennox-Gastaut syndrome (ICD-10: G40.81)
  • REMS program enrollment confirmation
  • Baseline echocardiogram results (required due to cardiac safety concerns)
  • Current seizure frequency and functional impact assessment
  • Weight-based dosing calculation

Clinical Justification:

  • Detailed seizure history and current frequency
  • Impact on daily functioning and quality of life
  • Previous hospitalizations or emergency department visits due to seizures
  • Caregiver burden documentation
Clinician Corner: The introduction of specific ICD-10 codes for Dravet syndrome (G40.83) in 2020 significantly improved insurance approval rates by distinguishing it from generic epilepsy classifications. Ensure your electronic medical records system uses these updated codes rather than the outdated G40.8 designation.

Step Therapy Documentation

Blue Cross Blue Shield typically requires documentation of failed trials with preferred anti-seizure medications before approving Fintepla. Based on clinical criteria from other Blue Cross Blue Shield plans, you'll need to document trials with:

Required Prior Medications

Medication Documentation Needed
Clobazam Trial duration, maximum tolerated dose, reason for discontinuation
Valproate Efficacy results, side effects, contraindications
Stiripentol Specific use in Dravet syndrome, outcomes
Cannabidiol (Epidiolex) Trial results, tolerability issues

Step Therapy Exception

You can bypass step therapy requirements if you have documented contraindications to preferred medications. Submit a step therapy exception request with:

  • Medical contraindications to required drugs
  • Allergy documentation
  • Previous severe adverse reactions
  • Drug-drug interaction concerns

Common Denial Reasons & How to Fix Them

Denial Reason How to Overturn
Missing REMS documentation Submit REMS enrollment certificate and baseline echo
Diagnosis not supported Provide genetic testing results, detailed seizure logs
Step therapy not completed Document failed trials or submit contraindication evidence
Not medically necessary Include functional assessment, seizure frequency data
Experimental/investigational Cite FDA approval and clinical guidelines

Internal Appeals Process

If your Fintepla request is denied, you have 180 days from the denial date to file an internal appeal with Blue Cross Blue Shield.

Step-by-Step Appeal Process

  1. Gather Your Documentation (Day 1-3)
    • Original denial letter with claim number
    • Complete medical records
    • Clinical evidence supporting medical necessity
    • REMS enrollment confirmation
  2. Complete the Appeal Form (Day 4-7)
    • Download the Reconsideration Request Form from your plan's website
    • Include patient information, denial details, and requested action
    • Attach supporting documentation
  3. Submit Your Appeal (Day 8-10)
    • Submit via online portal for fastest processing
    • Send certified mail as backup with return receipt
    • Keep copies of all submissions
  4. Request Peer-to-Peer Review (Within 72 hours of submission)
    • Contact Blue Cross Blue Shield to schedule
    • Prepare your neurologist for direct discussion with medical director
    • Focus on unique clinical circumstances

Appeal Timeline Expectations

  • Standard Appeals: 30 calendar days for decision
  • Expedited Appeals: 72 hours (for urgent medical situations)
  • Pre-Service Appeals: 15 calendar days
Important: If Blue Cross Blue Shield doesn't respond within required timeframes, federal ERISA regulations require automatic approval of your appeal.

External Review in Ohio

If your internal appeal is denied, Ohio law provides the right to external review through an Independent Review Organization (IRO).

External Review Process

Timeline: File within 180 days of final internal denial

Process:

  1. Submit external review request to your health plan
  2. Ohio Department of Insurance assigns case to qualified IRO
  3. IRO reviews complete medical records and plan policies
  4. Decision issued within 30 days (72 hours for expedited)

Key Benefits:

  • No cost to you
  • Decision is binding on the insurance company
  • Independent medical experts review your case

Contact Information: Ohio Department of Insurance Consumer Hotline: 800-686-1526

Templates and Scripts

Patient Phone Script for Blue Cross Blue Shield

"Hello, I'm calling about a prior authorization denial for Fintepla for my [child/myself]. The denial letter shows claim number [X]. I'd like to file an internal appeal and request a peer-to-peer review with your medical director. Can you please send me the appeal form and connect me with someone who can schedule the peer-to-peer discussion?"

Medical Necessity Letter Checklist

Your neurologist should include:

  • Problem Statement: Specific diagnosis with ICD-10 code
  • Prior Treatments: Detailed history of failed medications with dates, doses, and outcomes
  • Clinical Rationale: Why Fintepla is medically necessary
  • Guideline Citations: FDA labeling, epilepsy society recommendations
  • Monitoring Plan: REMS compliance, cardiac monitoring schedule

Cost Assistance Programs

While pursuing insurance approval, explore these financial assistance options:

Manufacturer Support:

  • UCB Patient Access Program may provide copay assistance
  • Contact UCB directly for eligibility requirements

Foundation Grants:

  • Patient Advocate Foundation
  • National Organization for Rare Disorders (NORD)
  • Epilepsy Foundation

State Programs:

  • Ohio Medicaid may cover Fintepla with prior authorization
  • Contact Ohio Department of Medicaid for eligibility

At Counterforce Health, we specialize in turning insurance denials into successful appeals by crafting evidence-backed, payer-specific requests that address the exact denial reasons. Our platform analyzes denial letters, plan policies, and clinical documentation to create targeted appeals that significantly improve approval rates for specialty medications like Fintepla.

Frequently Asked Questions

How long does Blue Cross Blue Shield prior authorization take in Ohio? Standard prior authorization requests typically receive decisions within 15 calendar days. Expedited requests for urgent medical situations are processed within 72 hours.

What if Fintepla is not on my formulary? You can request a formulary exception by demonstrating medical necessity and failure of preferred alternatives. Include documentation of contraindications or inadequate response to formulary drugs.

Can I request an expedited appeal? Yes, if delays could seriously endanger your health. Expedited appeals receive decisions within 72 hours and can be requested simultaneously with expedited internal appeals.

Does step therapy apply if I tried medications outside Ohio? Yes, previous medication trials from other states count toward step therapy requirements. Provide complete medical records documenting these trials.

What happens if my appeal is denied? You can request external review through the Ohio Department of Insurance within 180 days. The external review is conducted by independent medical experts and the decision is binding on your insurance company.

Who can help me with the appeals process? Contact the Ohio Department of Insurance at 800-686-1526 for assistance. Counterforce Health also provides specialized support for complex specialty drug appeals.

How much does Fintepla cost without insurance? The typical cash price is approximately $1,595 for a 30-mL bottle, though total monthly costs vary based on weight-based dosing requirements.

Do I need a specialist to prescribe Fintepla? While not always required, neurologists or epileptologists are typically best positioned to provide the comprehensive documentation needed for insurance approval and REMS program compliance.

From Our Advocates: We've seen cases where families spent months trying to navigate the appeals process alone, only to succeed quickly once they provided the specific clinical documentation Blue Cross Blue Shield required. The key is understanding exactly what your plan's medical policy demands and addressing each criterion systematically. Don't give up after the first denial—well-documented appeals have success rates of 70-78%.

Sources & Further Reading

Disclaimer: This information is for educational purposes only and does not constitute medical or legal advice. Insurance policies vary by plan and state. Always consult with your healthcare provider and insurance company for specific coverage decisions. For additional assistance with Ohio health insurance appeals, contact the Ohio Department of Insurance at 800-686-1526.

Powered by Counterforce Health—AI that turns drug denials into evidence-based appeals patients and clinicians can submit today.